MEDICARE: SOUTHEAST X-RAY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center

General Provider Information

NPI Number	:	1154565802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST X-RAY, INC.

Provider Business Mailing Address
First Line	:	22601 N 19TH AVE STE 108
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-1324
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	22601 N 19TH AVE STE 108
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-1324
Country	:	US
Telephone Number	:	480-369-1270
Fax Number	:

Authorized Official
Title or Position	:	CHIEF STRATEGY OFFICER
Name	:	ROBERT SCOTT THORNOCK
Credential	:
Telephone Number	:	480-369-1270

Provider Enumeration Date	:	04/24/2009
Last Update Date	:	04/23/2026

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Directions to “SOUTHEAST X-RAY, INC. ” Practice Location

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